PCS Form, required on all non-emergent ambulance transports, IMPORTANT: if the trip is repetitive like dialysis, the form must be signed by a PHYSICIAN 

Letter of Agreement, this is required if the facility or other non-insurance organization is going to pay for services.



Medicare B may cover the following types of ambulance trips


  • Emergencies

  • Transfer to the hospital, when the patient will be admitted to the hospital and if the patient will return to the sending facility within 24 hours. 

    • SO if you are discharging the patient from the ED and they came in that same day, the trip may not be covered. ​

  • Discharges from a Hospital to skilled nursing, home, or long term care.

  • Hospital to Hospital, when the sending facility does not offer medically necessary services and only if the patient is to be discharged from one hospital and admitted to another. 

Medicare B will NOT Cover the following types of ambulance trips 

  • Transfers to physician's offices, diagnostic centers, round trips to hospitals, and transfer types not listed above. 

  • Transfers to and from or between; Skilled Nursing, Home, Board & Cares. 

  • Hospital to Dialysis 

  • Physicians office to Dialysis 

Insurance Authorizations

Double the units for round trips:

AO428 BLS Ambulance 1 Unit per trip

AO425 BLS Miles 1 Unit per mile of the trip (Multiple Units per trip)

AO426 ALS Ambulance 1 Unit per trip 

AO434 CCT Ambulance 1 Unit per trip

AO422 Oxygen needed, 1 Unit per trip

Multiple Units per trip, the patient may require multiple units per each trip, double these for round trips:

  • AO424 Extra Attendant, TYPICALLY 1 Unit, in rare cases more per trip

    • CCT, Ventilator Used, Bariatric Patients....

  • AO420 Wait Time, 1 unit per 30 minutes that the patient is expected to be an appointment


For example, a patient is being transported 10 miles BLS with oxygen from a nursing home to a CT barium swallow test;

  • TRIP # 1 :

    • 1 Unit AO425 

    • 10 Units AO425

    • 1 Unit AO422

    • 1 Unit AO420 

  • Return Trip: 

    • 1 Unit AO425 

    • 10 Units AO425 

    • 1 Unit AO422 

  • Total Units

    • 2 Units AO428 

    • 20 Units AO425

    • 2 Units AO422

    • 1 Unit AO420 


Redirected / Forwarded Claim 

Claim Follow Up 

PCS, Document & Auth Request 

SNF Billing Letter 

Missing Auth Not Covered  

Medicare SNF Appeal